Root Cause and Data Analysis Michelle Synakowski LeadingAge NY Policy Analyst/Consultant 2 1
3 Systemic Analysis and Action Systematic approach to problem analysis Thorough Highly organized Structured Root cause of problem Delivery or organization of care and services Proficient in use of Root Cause Analysis Policies and Procedures define process 4 2
Feedback, Data Systems and Monitoring Systems to monitor care and services Data from multiple sources Feedback systems - Residents - Families - Staff - Others Use of Performance Indicators to monitor processes and outcomes Tracking Investigating 5 Develop a data strategy Identify the sources of data: Input from caregivers, residents, families and others Adverse events Performance Indicators (QMs, 5-star etc.) Survey and complaint findings Clinical records (MDS) QAPI plan must describe process for collecting and analyzing the data and how findings will be reviewed against benchmarks and/or targets set by the facility 6 3
Identify Your Gaps and Opportunities Review sources of information (data) to determine if gaps or patterns exist in your systems that could result in quality problems: Look at MDS data for patterns Log onto NHC (QMs, staffing, survey) Trends in survey issues/complaints? Review Resident and Family satisfaction for trends ER/hospital use Caregiver turnover Clinical Records This step should lead to development of Performance Improvement Projects (PIPs) 7 Analyzing the Data 8 4
Root Cause Analysis What is the REAL cause(s) of the problem? Root Cause Analysis Potential Contributing factors: Procedure/Policy not based on Regulation Knowledge of Regulations Staff knowledge and education Accountability Communication Normalizing Behaviors: accepting the unacceptable Quality Assessment/Assurance Process 5
Useful Relevant Specific Data Principles Sufficient to assist in identification of root cause. Think of possible root causes when determining the data to collect Data? What data? Determine data needed What do we want to know? How detailed do we want to be? Determine method to collect the data Who will get the data? What source do we need to obtain the data from? 6
Data? What data? Determine how to evaluate the data Who will evaluate the data? How will it be evaluated? Benchmarks? Facility State National Tracking over time? 14 7
Examples of Data Rehospitalization From what? How soon? How many times? What shift? What nurse? Doctor involved? Early intervention? Insidious onset? Decline noted? Examples of Data Infection rates Type of infections? Specific unit? 8
Examples of Data Pressure Ulcer Rates Incidence Prevalence When developing? Where? What unit? What stage are they found at? Who is finding them? Preventative measure in place? Examples of Data In-house Fractures and Injuries Incidence How? When? Where? What unit? Shift? Hour? Why? 9
Examples of Data Weight Loss Incidence When? Within 30-60 days of admission? Where? What unit? Why? Don t like the food Poor staff supervision Lack of timely intervention Data without analysis is useless What is the data telling you? 10
Let s look closer at some data Rehospitalization From what? How soon? How many times? What shift? What nurse? Doctor involved? Early intervention? Insidious onset? Decline noted? and Data Analysis Rehospitalization data received: 5 hospitalizations 1 day shift, 4 evening shift, 0 night shift 1 from Unit One, 4 from Unit Two 4 from Unit Two were all while Nurse Jones was on duty 3 admitted with dehydration, 1 UTI/Sepsis, 1 Pneumonia None were seen by the physician in the week prior to hospital admission 11
Deductions? What shift would you focus on? Evenings? Maybe the problem is actually on Days? Why didn t Days provide intervention? Notify the Doctor? Is it that the nurse on Evenings is nervous or that she is very skilled in assessing the need for intervention? What would your PIP look like? Do you have enough information? Deductions? What do Dehydration, UTI, and Pneumonia have in common? Is the root of the problem really a hydration concern? If it is a hydration problem, is there a deeper root? 12
Deductions? Could there be more than one root cause? Assessment skills of the nurses Notification of the physicians Intervention by the physicians Evaluating overall effectiveness of the Hydration Program Getting to the Root of the Problem What is the REAL cause(s) of the problem? Need to look at all possible contributing factors Many times there is more than one root cause Don t stop when you get to one possible cause 26 13
Potential Contributing Factors Procedure/Policy not based on Regulation Knowledge of Regulations Staff knowledge and education Accountability Communication Normalizing Behaviors: accepting the unacceptable Quality Assessment/Assurance Process 27 Sample Root Cause Tools Diagrams: May be most helpful with systems or training breakdown Helps brainstorm about main causes and subsequent causes Fishbone Tree Analysis Cause and Effect Pareto Chart (80/20 rule) Trend Chart (over time) Why-Why (5 Whys): Helps drill down deeper to subsequent causes 28 14
Sample Root Cause Tools Brainstorming/Structured Discussions: Helps evaluate and prioritize subsequent causes Can generate multiple ideas in a short period of time Ensure everyone has an opportunity to participate in discussion or written idea submission Storytelling Method: Incident Reports Predefined Stops before the end of the story 29 30 15
Pareto chart The Pareto theory proposes 20% of the causes contribute to 80% of the problem. 31 Tree Diagram 32 16
Fish Bone Diagrams Look at Cause and Effect Drill down to specific causes Many problems have multiple causes Fish Bone Diagrams 17
Why-Why Chart One of many brainstorming methods also known as the Five Whys method. Most simplistic root cause analysis process Involves repeatedly asking why? 5 times or until you can no longer answer the question 5 is arbitrary Increased staff participation The root cause has been identified when asking why doesn t provide any more useful information 35 5 Whys PROBLEM: Man runs out of gas Why did you run out of gas? Because I didn t put gas in the car. Why didn t you put gas in the car? Because I didn t have any money. Why didn t you have any money? Because I spent it at the casino. Why did you spend all your money at the casino? Because I kept losing. Why did you keep losing? Because I am bad at gambling. (ROOT CAUSE) 36 18
5 Whys PROBLEM: Residents falling on Unit 2 Why are residents falling on Unit 2? They are getting up without assistance. Why aren t they getting assistance? They aren t asking for assistance. Why aren t they asking for assistance? They think the staff are too busy. Why do they think the staff is too busy? Because the staff tell the residents they are short staffed Why are the staff telling the residents they are short staffed? So the residents will tell management. ROOT CAUSE: Communication between staff and management 37 38 19
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Quality Improvement Fundamentals Tool Kit http://www.ofmq.com/websites/ofmq/image s/qi_fundamentals_508.pdf 47 24